Radical revision of survey process may ease compliance burden

Self-assessment, other changes designed to make surveys more relevant

Responding to years of criticism and pleas from health care providers, the Joint Commission on Accreditation of Healthcare Organizations has announced a major overhaul of the survey process that it says will make accreditation more relevant to actual patient care and less onerous for organizations being surveyed. Under the new plans, hospitals and other providers will conduct self-assessments long before surveyors show up, and the surveyors will focus on actual patient care experiences instead of more theoretical compliance with standards.

John Noble, MD, chairman of the Joint Commission’s Board of Commissioners, says the board agreed that "now is the time for the Joint Commission to take bold action," and so it "radically revamped the accreditation process." The new plan will go into effect January 2004 for all Joint Commission-accredited organizations. Called "Shared Visions — New Pathways," the new process is very different from the system that now takes up so much of a quality manager’s time. These are the major components of the new process:

  • Streamlined standards and a reduced documentation burden, with more focus on critical patient care issues.
  • Self-assessment process intended to support an organization’s continuous standards compliance while freeing up survey time to focus on the most critical patient care issues.
  • System for focusing surveyors on specific areas that need attention during their visit. Organization-specific data are used to highlight these areas.
  • New survey system with six basic components that will replace the standard triennial survey format. The system starts with an opening conference between surveyors and hospital leaders, which is followed by a leadership interview, validation of self-assessment results, a focus on actual patients as the framework for assessing compliance with selected standards, discussion and education on key issues, and a closing conference.
  • More training, requirements, certification, and an enhanced role for surveyors. Surveyors will have to be certified and then recertified every five years.
  • Revised decision and performance reports providing more meaningful and relevant information.
  • The use of ORYX core measure data to identify critical processes and help organizations improve throughout the accreditation cycle.
  • Better engagement of physicians in the new accreditation process.
  • New approach to surveying complex organizations.

The new survey process will be more continuous and eliminate much of the "ramp-up" before a scheduled survey, says Dennis O’Leary, MD, president of the Joint Commission. A task force is continuing its efforts to review all Joint Commission standards and eliminate those that are redundant or unnecessary, he says.

"We’re consolidating, saying things in a lot fewer words, and moving standards to the most appropriate sections," O’Leary says. "We have reduced the number of scorable elements, and that has a significant impact in terms of the burden on accredited organizations."

Perhaps the biggest component of this change is the self-assessment, in which the organization looks for much of what the surveyors would have looked for in the triennial survey. An accredited organization will complete the self-assessment at the 18-month point in its three-year accreditation cycle, rating its level of compliance with all standards that are applicable. There will be no surveyor visit at this point; the organization will submit its own self-assessment ratings by a secure Internet site.

If an organization finds it is not compliant in any standards area, it must detail the corrective actions it has taken or will take to comply. This information will not result in any change in accreditation status, O’Leary says. Once the information is submitted, a Joint Commission representative will contact the organization to review the findings, approve the corrective actions, and provide advice on taking those actions. At the 36-month point, the time for the triennial survey, surveyors will visit the site to verify that the corrective actions have been taken. The surveyors also will validate the self-assessment by reviewing specific critical areas.

Providers that are at or beyond the midpoint of their accreditation cycles as of January 2004 (meaning they are due for a survey in July 2005 or after) will receive the self-assessment tool in July 2003 or thereafter. Once you receive the self-assessment tool, you will have three to six months to complete it and plan any corrective actions.

That process is supposed to help organizations identify most problems long before the surveyors show up at the door, O’Leary says. And once the surveyors arrive, the experience should be quite different from any survey they’ve had in the past. The biggest change during the on-site survey involves what the Joint Commission calls "tracer methodology." In short, that means that surveyors will trace the experience of actual patients through the organization’s system to determine compliance with Joint Commission standards, instead of quizzing staffers and studying representative documents.

That system will focus the survey process more on actual patient care than on theoretical compliance with standards, says Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission.

"In the past, surveyors might have asked what steps you take to prevent wrong-site surgery, and the organization would talk about procedures, education, and other steps," he says.

"In the future, we’ll get at the same information but in a different way. We will choose at random from open records a patient who has just had surgery, and we’ll trace that patient through the process, Massaro explains. The surveyor will go to the [emergency department] and ask how they X-rayed the patient, how they obtained consent, and so on. Then if the patient went to a unit, the surveyor will go there and talk about preoperative preparation. Then they’ll go to the [operating room] and ask When this patient came up, was the site marked? Did you have a timeout before you began surgery to discuss whether this was the right patient and what procedure you were doing?’"

All of the questions pertain to the actual patient being traced, derived from the chart.

That kind of focus on actual patient care, as opposed to formal standards that supposedly affect patient care, draws more physicians into the accreditation process, says William Richardson, CEO of Tift Regional Medical Center in Tifton, GA, one of two hospitals that conducted pilot tests of the new accreditation process.

The changes make the overall accreditation more meaningful and less like an academic exercise, he says.

"For the first time as a CEO, I see the pertinence of the methodology," Richardson says. "I understand the standards better and see the relevance to patient care."

The same reaction comes from Chuck Young, administrator at Shriners Hospitals for Children in Spokane, WA, the other hospital testing the pilot program. Physicians at his hospital reacted most strongly to the difference in the accreditation process, he says. They responded favorably when they saw that the accreditation process was focusing on actual patient care and real patient experiences.

"In many cases, our physicians were not so involved in past surveys," Young says. "They’re responsible for so much of what goes on in a hospital, but it was those of us who are hands-off who were being surveyed. Now the surveyors will be actually out on the floor seeing what happens to patients, and physicians see that as a sign that they’re focusing on what really matters. You have a hard time getting physicians to care about something just because it’s in a standard, but they’ll care if you’re looking at what actually happens to patients."

Costs and effort should be reduced

The Joint Commission promises that the new and improved survey system will be less expensive and less burdensome on providers. The average triennial survey fee for a hospital is $20,000, but O’Leary says accredited organizations usually don’t complain about that. They complain about the cost of "ramping up" for a survey — all the improvements, consulting fees, and other preparation that goes into a triennial survey.

"Ideally, they should be ready for a survey all the time, but the fact is they do incur costs for the ramp-up," he says. "I’ve heard figures of a quarter million, half a million, numbers with lots of zeroes after them. We can get rid of that terrible expense if we have a survey process that inherently ensures the hospital is in compliance all the time."

Under the new system, you should be able to make smaller, more incremental changes over time and ultimately be more in compliance than when you were scrambling to get things in order for a triennial survey, O’Leary says.

Young says that was the experience at Shriners Hospitals when they were testing the pilot program for the new plan.

"We prepared for the mock survey under this new program as if someone were coming for dinner, and we did very well," he says.

"When surveyors are coming for real after 2004, we will prepare as if the in-laws are coming to stay for a week. Sure, we’ll get some things in order and put our best foot forward, but we won’t have to spend all this money on the ramp-up that you see now. It will be more a matter of cleaning up the house before guests come," Young adds.

(In next month’s Hospital Peer Review, look for much more information about how the changes in the survey process will affect you and how you can prepare.) n